Challenging Closure of Defects Following STS Excision of Calf Region; Bringing the Attention of Oncosurgeons

Introduction: When it comes to the closure of defects following excision of STS of calf where primary closure might not be an option. Delayed closure, as well as grafting of a wound are well documented options and should be attempted in both the simple wound, those where early recovery is required. Local rotation advancement flaps give better postoperative recovery rates where more complex reconstructive failure would be disastrous. These perforator based local flap have been observed to have better recovery outcomes and makes the patient able to finish adjuvant treatment timely in such cases

Pre-requisites: Both of these options require an adequate blood supply to the wound area and relatively reliable surrounding tissue. Where the blood supply is poor, or where there is a requirement of soft tissue depth, the use of reconstructive flaps is generally required. This technique is limited by the reliability of the surrounding tissue, but may offer a potential donor site for both direct closure and local flap coverage.

Choice of Reconstruction

1. Upfront cases / treatment naive cases: Traditionally the use of local flaps proximal based or distal based have been used to cover calf defects and reliability on local fascio-cutaneous flap have also contributed to their increased use throughout the limb

2. Recurrent cases: Where defects are supposed to be larger, combination of both local perforator based flap, and distal free flaps can result in acceptable oncoplastic outcome and role of plastic surgeon plays an important role.

3. Melanoma of calf: This entity unlike other pathological subtypes of STS may pose a challenge when it comes to reconstruction using local flaps.

4. V-Y flaps: As described by Blasius, are another option, particularly around the ankle and calf especially lateral compartment defects and can provide a sensate flap to the region

Precautions

1. Proper preoperative land marking of perforators of the region.
2. Intraoperative hand held Doppler to confirm vascularity of the harvested perforator based fascio-cutaneous or muscle based flaps.

Conclusion: The salvage of the limb is preferred over amputation. Soft tissue coverage must be wound and area specific, involving the patient and a multidisciplinary approach.